In October 2011, California became the first US state to ban indoor tanning for minors under age 18 years. Vermont followed in May 2012. Increasingly, scientific evidence shows that artificial tanning raises the risk of skin cancer, including melanoma, a common cancer in adolescents and young adults and the type most likely to result in death. The World Health Organization, the American Academy of Pediatrics, the American Academy of Dermatology, the American Medical Association, and other organizations strongly recommend legislation to ban minors under age 18 from indoor tanning. Several nations have banned teen tanning. Yet, tanning in salons is still a prevalent practice in the United States, especially among teen girls, where rates for the oldest teens approach 40%. There is no federal legislation to restrict minors from salon tanning. More than 60% of states have some kind of legislation regarding minors’ use of tanning salons, but only California and Vermont have passed complete bans of indoor tanning for minors. The Indoor Tanning Association, an industry advocacy group, has vigorously opposed legislative efforts. Pediatricians can play key roles in counseling families and with legislative efforts. In this update, we review the prevalence of salon tanning, association with skin cancer risk, tanning addiction, the roles of the federal and state governments in regulation and legislation, and responses to arguments created by industry to oppose legislation. Preventing exposure to artificial tanning may save lives, including young lives, and is a key cancer prevention opportunity for pediatricians.
- indoor tanning
- artificial tanning
- skin cancer
- tanning addiction
- tanning legislation
- BCC —
- basal cell carcinoma
- FDA —
- US Food and Drug Administration
- FTC —
- US Federal Trade Commission
- ITA —
- Indoor Tanning Association
- NMSC —
- nonmelanoma skin cancer
- POMC —
- SCC —
- squamous cell carcinoma
- USPSTF —
- US Preventive Services Task Force
- UVR —
- UV radiation
People may be exposed to artificial sources of UV radiation (UVR) for treatment of certain medical conditions, in occupational settings, and for cosmetic purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor tanning started in the 1970s and has grown rapidly. Now >1 million people in the United States tan in tanning salons each day.2 Many of those who visit tanning salons are adolescent girls and young women. According to the 2009 Youth Risk Behavior Survey, a nationally representative sample of high school students in grades 9 through 12, 15.6% of all students used an indoor tanning device ≥1 times during the 12 months before the survey. Among students who reported using devices within the past year, 49.1% reported doing so ≥10 times. Female students and white students were more likely to use tanning devices ≥10 times. More than one-quarter (25.4%) of girls reported using a tanning device in the past year.3 The rate of artificial tanning among white girls increases with age, doubling from ages 14 to 15 (7% to 15%), and doubling again at age 17 (35%).4 Tanning salons are ubiquitous. The average US city has 41 salons, outnumbering the number of Starbucks or McDonalds.5 Access is easy. Salons are inexpensive and often offer “unlimited” tanning packages.6 Adolescents are specifically targeted through advertising strategies that include promoting purported cosmetic and health benefits.6
Young adults and some adolescents have opportunities to access indoor tanning in nonsalon locations, including apartments, beauty salons, and fitness centers. Regulations governing minors’ access to tanning salons do not affect these sites, and there is little scientific information available about them.
Radiation Emitted by Tanning Devices
Tanning devices emit primarily UV-A radiation.7 UV-B radiation is much more potent than UV-A in causing sunburn, but high fluxes of UV-A can cause erythema in people who are sensitive to sunlight. In people who tan easily, exposure to tanning devices results in immediate pigment darkening caused by oxidation of existing melanin. A more permanent tan occurs with additional exposure, depending on the individual’s tanning ability and the amount of UV-B in the lamps.7 UV-B exposure results in greater tanning; newer tanning lamps may emit a greater proportion of UV-B.
The doses of UV-A emitted by high-pressure tanning units may be up to 10 to 15 times higher than that of the midday sun, an intense exposure not found in nature.8,9 Frequent indoor tanners may receive 1.2 to 4.7 times the yearly dose of UV-A received from sunlight, in addition to doses from sun exposure.1
Skin Cancer Incidence
The incidence of skin cancer has reached epidemic proportions. Skin cancer (including basal cell carcinoma [BCC], squamous cell carcinoma [SCC], and melanoma) is by far the most common cancer. Approximately 3.5 million BCCs and SCCs in >2 million Americans are diagnosed each year.10,11 BCC and SCC (grouped together as nonmelanoma skin cancer [NMSC]) are less likely to result in fatality compared with melanoma. Nonetheless, the American Cancer Society estimates that ∼2000 people die each year of NMSC.10 There is considerable morbidity and cost associated with treating NMSC. The American Cancer Society estimates that 76 690 new melanomas will be diagnosed in 2013; ∼9480 people are expected to die of melanoma in 2013. US incidence rates for melanoma have been rising in all age groups since first recorded in 1973.12
Melanoma is more likely to occur in males and at older ages but also occurs in teenagers and in young adults. Melanoma is the second most common cancer in women in their 20s and the third most common cancer in men in their 20s.13 Data from the SEER (Surveillance, Epidemiology, and End Results) Program show that the age-adjusted annual incidence rate for women aged 15 to 39 years more than doubled from 5.5 per 100 000 (range: 4.5–6.6) in 1973 to 13.9 per 100 000 (12.7–15.2) in 2004. The rise in the incidence rate for women has been sharpest since 1992 (Fig 1). Melanoma incidence increased for both thin and thick tumors and was greater for regional and distant tumors compared with localized lesions.14 In Olmstead County, Minnesota, melanoma incidence increased 4-fold in young men but 8-fold in young women over a 30-year period: among men ages 18 to 39 years, the incidence rose from 4.3 per 100 000 between 1970 and 1979 to 18.6 per 100 000 between 2000 and 2009; among women ages 18 to 39 years, the incidence rose from 5.4 per 100 000 between 1970 and 1979 to 43.5 per 100 000 between 2000 and 2009.15 Experts believe that 1 reason for this dramatic increase is the increasing popularity of artificial tanning,15 especially among young women.
The incidence of NMSC also is increasing in young adults. Between 1976 and 2003, the incidence of BCC increased significantly among young women (<40 years of age), and the incidence of SCC increased significantly among men and women.16 A trend toward a greater number of BCC cases occurring on the torso in younger patients has been reported.16–18 This change in location supports the possibility that excessive outdoor tanning, use of tanning booths, or both give rise to BCC. The use of tanning beds has been shown to be a risk factor for NMSC in young women.19
Tanning Results in DNA Damage
The skin is composed of the epidermis, dermis, and subcutaneous layer. The top layer, the epidermis, includes basal cells, squamous cells (together known as keratinocytes), and melanocytes. Keratinocytes produce keratin, which is a structural and protective protein. Melanocytes produce melanin, a family of pigments spanning brown-black to blond-red colors. After their synthesis in melanocytes, melanin-containing vesicles are transported to overlying keratinocytes, where they traffic selectively to the sun-exposed side of nuclei. Darker melanins appear to protect the skin by absorbing UVR and reactive oxygen species.
Recent evidence indicates that the tanning response is mediated, in significant part, by signals emanating directly from damage to DNA. Exposure to UVR triggers DNA damage in the nuclei of keratinocytes, activating the p53 tumor-suppressor protein, a transcription factor that plays a pivotal role in the cellular response to genotoxic stressors such as UV- and chemically induced DNA damage.20 p53 directly activates transcription of numerous genes such as those that regulate cell-cycle progression and apoptotic cellular pathways. p53 function is critical for the retention of tissue integrity after UV irradiation of skin. Loss of function of p53 leads to aberrant cell growth and survival responses; dysfunction of p53 plays an integral part in human cancer development.20
p53 activation in the skin leads to upregulation of the gene that encodes pro-opiomelanocortin (POMC), a polypeptide precursor present throughout the central nervous system and skin. POMC is then processed to produce α-melanocyte–stimulating hormone, which after secretion, stimulates its receptor, the melanocortin 1 receptor on the surface of melanocytes, to induce the synthesis, maturation, trafficking, and secretion of melanin. After the uptake of melanin by overlying keratinocytes, skin takes on a darker appearance, which results in tanning (Fig 2).21 Thus, tanning occurs as a response to DNA damage and appears to be a component of the p53-induced stress response. Any wavelength of UV (ie, UV-A or UV-B) that is capable of inducing tanning (thus elevating carcinogenic risk) appears to do so via damage to DNA as a first step because the DNA damage response factor p53 is a key mediator of the tanning pathway.20
Acute and Long-term Effects of Exposure to Artificial Tanning
Exposure to artificial UVR often results in erythema and sunburn. Erythema or burning was reported in 18% to 55% of users of indoor tanning equipment in North America and Europe.1 A large US study of teen tanning-bed use revealed that 57% experienced at least 1 sunburn during a salon visit.22 Other reported effects include skin dryness, pruritus, nausea, photodrug reactions, disease exacerbation (eg, systemic lupus erythematosus), and disease induction (eg, polymorphous light eruption). Long-term health effects include skin aging, effects on the eye (eg, cataract formation), and carcinogenesis.7
Artificial Tanning Is Carcinogenic
In 2006, the International Agency for Research on Cancer (a branch of the World Health Organization) issued a report1 based on meta-analysis of 19 studies of associations between tanning-bed use and skin cancer risk. On the basis of these data, in 2009 the International Agency for Research on Cancer declared that UVR from salons was a group 1 carcinogen (ie, known to cause cancer in humans).23 These findings were criticized by some because of the weak association and inability to confirm a dose-response relationship or examine exposure to specific tanning devices. Since then, new studies have strengthened the association of tanning-bed use with increased melanoma risk (Table 1). In 2012, a meta-analysis of 27 observational studies showed that for users of indoor tanning devices the risk of melanoma increased 20%, which doubled if tanning started when users were younger than 35 years.9
Why People Tan
Despite evidence that UVR exposure increases skin cancer risk, people continue to intentionally tan. Knowledge about the dangers of UVR often does not change tanning behavior.24,25 These practices may persist because many people believe that a tanned appearance is attractive and healthy. In 1 study, 67.8% of youth agreed with the statement “I look better when I have a tan” and 55% agreed with the statement “I feel healthy when I have a nice tan.”26 In addition to the desire for improved appearance, motivations in some tanners include relaxation and a better mood. In view of potentially severe consequences, it has been postulated that continued and frequent use of tanning beds shares characteristics with addictive disorders,27 and that for some individuals, tanning behavior may be motivated, at least in part, by a type of UV light substance-related disorder.
To characterize possible tanning addiction, researchers have used surveys that included tanning-specific modifications of 2 established instruments. The CAGE (Cut down, Annoyed, Guilty, Eye-opener) Questionnaire screens for alcohol abuse or dependence. Modifications include questions about whether tanners wanted to cut down but nevertheless continued and whether tanners felt annoyed when others advised them not to tan. The second instrument uses a modification of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, criteria for substance-related disorders. Questions include tolerance to tanning (ie, need for increased amounts of tanning to achieve a desired effect), withdrawal symptoms, and loss of control such as use despite a desire to cut down. Table 2 describes some studies of tanning addiction.
A small study found increased plasma concentrations of β-endorphin after UVR exposure in frequent tanners.28 Other studies have not observed such elevations.29,30 Blood endorphin concentrations appear to fluctuate through the day, so these studies might be limited, and more research is needed. It is interesting to consider whether an endorphin-mediated addictive mechanism might have conferred an advantage to human survival. UVR exposure results in conversion of vitamin D precursors in skin to vitamin D; adequate vitamin D is needed to ensure human survival.31 Among the cleavage products of POMC are the glucocorticoid precursor adrenocorticotropic hormone (ACTH) and β-endorphin, an endogenous ligand of the μ-opioid receptor. Endogenous β-endorphin exerts analgesic effects and promotes feelings of relaxation and well-being, similar to exogenous opiates such as morphine. It is thought that selection for fair skin and poor tanning ability was associated with migration of human populations to high-latitude geographic locations (with limited UV exposure, especially during winter months). It is possible that endorphin release may have evolved to reward behaviors that augment UV exposure and vitamin D acquisition.32
How Tanning Devices Are Regulated
The US Food and Drug Administration (FDA) is the agency responsible for ensuring the safety and efficacy of medical devices and products that emit radiation, and thus regulates the manufacturers of tanning equipment.2 The FDA established classifications for ∼1700 different generic types of devices, each of which is assigned to 1 of 3 regulatory classes on the basis of the level of control necessary to ensure that the device is safe and effective. The class to which a device is assigned determines, among other things, the type of premarketing submission and application required for FDA clearance to market. Classification is also based on the risk posed to the patient and/or user.33Table 3 summarizes FDA regulatory classes.
Concerns have been expressed that tanning beds are misclassified and need stronger regulation and scrutiny. On March 25, 2010, the General and Plastic Surgery Devices Panel of the FDA Center for Devices and Radiologic Health Medical Devices Advisory Committee convened a public meeting to discuss tanning devices. Scientific information was presented about the risks posed from intentional UVR exposure through tanning lamps. Medical organizations urged the FDA to reclassify indoor tanning devices and to pass federal restrictions concerning their use. The Indoor Tanning Association (ITA; an industry advocacy group) presented counterarguments. The FDA continues to deliberate about possible reclassification.
Manufacturers of indoor tanning equipment are required to adhere to FDA requirements for sunlamp specifications, posting of warning labels,34 and provision of eye protection.6 The standard requires manufacturers to provide an exposure schedule in the product warning label.34 The FDA recommends that the exposure schedule for users depends on the user’s skin type.34 The FDA recommends, but does not require or enforce,35 an exposure schedule not exceeding a 0.75 minimal erythemal dose (defined as a dose resulting in minimal pinkness) 3 times during the first week of tanning, gradually increasing exposure after the first week, then gradually increasing exposure the following weeks until maximum tanning has occurred (∼4 weeks total) and then providing for maintenance of a tan by biweekly or weekly exposures of up to 4 minimal erythemal doses.34 There are limitations on the amount of UV-C emitted, but no regulation on the amount of UV-A and UV-B. Because the proportion varies, consumers may not be able to predict the outcome of a particular tanning session.6
The Tanning Industry
The indoor tanning industry has grown substantially over several decades and comprises 19 000 businesses employing 160 000 individuals, according to industry information.36 According to the ITA, ∼10% of the American public visits an indoor tanning facility each year.36 This percentage is dramatically higher for female teens and young women. The mission of the ITA is “to protect the freedom of individuals to acquire a suntan, via natural or artificial light.”37 The ITA claims that melanoma is not a problem of the young and that tanning at an early age does not increase melanoma risk and makes other claims of purported benefits. Table 4 lists some of these claims and the evidence-based arguments used by child health advocates to counter them.
Tanning Industry False Claims and Deceptive Practices
The US Federal Trade Commission (FTC) investigates false and deceptive advertising claims, such as the claim that tanning in salons is safer than tanning outdoors. The commission files a complaint when it has “reason to believe” that the law has been or is being violated. The FTC has the power to issue consent orders to ban further deception.38 The FTC issued a complaint against the ITA alleging that, in March 2008, the ITA launched an advertising campaign portraying indoor tanning as safe and beneficial. The campaign included 2 national newspaper ads, television and video advertising, 2 Web sites, a communications guide, and point-of-sale materials that were provided to ITA members. The ITA claimed that indoor tanning was safer than outdoor tanning because the amount of UVR is monitored and controlled and that it neither increased skin cancer risk nor posed a danger to consumers. The ITA also claimed that research showed that vitamin D supplements may harm the body’s ability to fight disease, and that a study from the National Academy of Sciences determined that “the risks of not getting enough ultraviolet light far outweigh the hypothetical risk of skin cancer.” The ITA stated that indoor tanning is approved by the government, misrepresenting the nature of FDA approval. In January 2010, the FTC issued a consent order and the ITA agreed to a settlement barring it from any further deception.38,39
In 2012, a minority investigative report commissioned by 4 Democratic members of the US House of Representatives Committee on Energy and Commerce described results of “sting” telephone calls made by congressional staff to 300 tanning salons nationwide. Congressional staff posed as 16-year-old women wanting to tan for the first time. On the basis of answers given by salon workers, the report concluded that salons target teenage girls with advertising and promotions, deny known risks of indoor tanning, provide false information on benefits of tanning, and fail to follow FDA recommendations on tanning frequency.40 The tanning industry questioned the veracity of the study and conclusions but acknowledged that they could improve on giving accurate and consistent information to customers.41
Regulation of the tanning industry has been lax.2 As of February 2013, there is as yet no federal legislation prohibiting minors from tanning in salons.
As of July 1, 2010, under the Affordable Care Act, indoor tanning services were levied with a 10% excise tax (the so-called tanning tax or tan tax). Tanning salons are required to receive a payment for indoor tanning services, report the tax quarterly and remit the tax to the Internal Revenue Service. Sunless tanning options such as spray tans and tanning lotions are not included. The “tanning tax,” a part of President Obama’s administration’s health care overhaul plan, is expected to raise 2.7 billion dollars over the next 10 years. The indoor tanning industry expressed vigorous opposition to the tanning tax.42
The Tanning Accountability and Notification (TAN) Act (HR 4767) was included in FDA Amendments Act of 2007. The TAN Act requires the FDA to conduct consumer testing to determine if warning labels on commercial tanning beds are positioned correctly and provide sufficient information pertaining to skin cancer risk.6,27
State and Local Legislation
In 2009, Howard County, Maryland, was the first US jurisdiction to ban tanning for minors under age 18. On October 8, 2011, California’s Governor Brown signed the first state law banning under-18 salon tanning, effective January 1, 2012. Vermont passed an under-18 ban in May 2012. The City of Chicago did so in June 2012 and Springfield, IL did so in September 2012. Currently, 33 states have at least minimal legislation regarding tanning by minors.43
Despite the existence of state laws, researchers and advocates have noted that current laws appear to have limited effectiveness, perhaps because most states’ policies permit use with parental consent and no states had bans on minors tanning when the study was conducted. It has been suggested that multipronged approaches are needed to reduce teens’ use of tanning salons.44
Enforcement of Legislation
Researchers conducted a telephone survey of informants in states with indoor tanning legislation to assess enforcement practices. At the time of the survey, 28 states had teen tanning regulations. One respondent from the most populous city in each state was interviewed. Licensure was required in 22 of 28 cities. Slightly less than half of cities gave citations to facilities that violated state law. Approximately 32% did not inspect tanning facilities for compliance with state law; another 32% conducted inspections less than annually. Of the 21 cities in states that had youth access laws, approximately half penalized those salons with known violations. The authors expressed concern about relatively low rates of annual inspections and citations. They recommended that future studies assess whether legislation, enforcement practices, or both affect indoor tanning practices.45
Legislation in Other Countries
Several nations have strong antitanning legislation. In 2009, Brazil imposed a total ban on the use and sale of tanning devices for cosmetic purposes for the entire population.46
In 2012, the state of New South Wales (population >5 million) in Australia announced a total ban by 2014.47 France, Germany, Austria, and the United Kingdom banned under-18 indoor tanning. South Australia imposed a ban for those younger than 18 and for anyone with type I skin, the type most susceptible to skin cancer. Finland allows only certain types of devices for indoor tanning use and requires inspections to ensure that regulations are upheld.46
Recommendations About Tanning Legislation
The World Health Organization,48 the American Academy of Pediatrics,49 the American Academy of Dermatology,50 the American Medical Association,51 the Canadian Pediatric Society,52 and others recommend legislation to ban minors younger than 18 years from tanning in salons.
Mothers’ behaviors and attitudes may influence teen tanning practices. A population-based survey found that indoor tanning in the year before the survey was 30% among 12- to 18-year-olds whose caregiver also reported tanning indoors.44 Investigators in Minnesota and Massachusetts conducted telephone surveys of adolescents aged 14 to 17 years and their female parents or guardians to determine their role in teen tanning attitudes and practices. Female parents’ behavior, concern about children’s indoor tanning practices, and permissiveness were significant independent contributors to teen tanning.53 In another study, researchers sent questionnaires to female college students to investigate whether first-time indoor tanning with one’s mother would influence the frequency of tanning later in life and whether it was associated with age of initiation. Participants who reported tanning with mothers during their initial experience were >4 times more likely to be heavy current tanners than those who initiated tanning alone or with someone other than their mother (odds ratio: 4.64; P < .001). Participants who tanned for the first time with mothers started tanning at a significantly earlier age than those who started tanning without mothers.54 Additional research from national studies is needed to determine the prevalence of artificial tanning in mothers of teens.
Parallels Between Smoking and Tanning
Researchers and advocates from the disciplines of tobacco control and indoor tanning met in November 2011 to discuss common challenges and lessons. By consensus, participants agreed that legislative remedies must be sought as part of comprehensive programs, including the following: higher taxes; education for parents, pediatricians, and policymakers; and counteradvertising to refute tanning industry claims.
Role of Pediatricians and Other Clinicians
Indoor tanning is practiced by as many as 35% to 40% of white adolescent girls. It is estimated that 25% of melanomas observed in young women might be attributable to using tanning beds.55 It therefore stands to reason that pediatricians have an obligation to discuss this potentially life-threatening practice with families. Although pediatricians are often considered trusted advisors to families, sometimes over years and decades, many do not take opportunities to discuss indoor tanning.56 This may be due, in part, to a general view that skin cancer prevention is primarily an issue for dermatologists. Yet, skin cancer prevention, a lifelong effort, is clearly a pediatric issue as well as a dermatology issue. By the time a teen or young adult arrives in a dermatologist’s office to evaluate a suspicious skin lesion (one that may be melanoma) the opportunity for prevention may have been lost.
Counseling by pediatricians to reduce UVR exposure is likely to result in behavior change in some teens and families. In July 2012, the US Preventive Services Task Force (USPSTF) published an update of their 2003 recommendation regarding the effectiveness of behavioral counseling to prevent skin cancer. The USPSTF stated that there was adequate evidence in the scientific literature to conclude that counseling delivered in the primary care setting can moderately increase the use of protective behaviors for fair-skinned people between the ages of 10 and 24 years. Successful counseling interventions used messages about skin cancer or about the effects of UVR exposure on appearance. Appearance-focused messages succeeded in reducing intent to use indoor tanning among late-adolescent women. Behavioral interventions were not associated with any known risks or harms. The USPSTF thus recommended counseling fair-skinned children, adolescents, and young adults about minimizing their exposure to UVR. Evidence was not sufficient to conclude that counseling resulted in behavior change in girls younger than age 10 or women older than 24 years.57 Under the Affordable Care Act, the health insurance reform legislation passed by Congress and signed into law by President Obama on March 23, 2010, counseling patients to avoid tanning beds (a recommendation receiving a “B” rating from the USPSTF) is a covered service and thus is fully reimbursable.58 The American Academy of Pediatrics and other organizations interested in pediatric health should consider interventions for the best methods in training pediatricians in tanning-bed avoidance counseling as well as informing them of the new covered service.
Because teens begin to take up tanning at 13 to 14 years of age, pediatricians may adopt a strategy of discussing indoor tanning at the 12-year-old well-child visit. Most parents state that they do not want their children to use tanning devices but most have not discussed tanning with their child.59 Pediatricians may influence tanning practices by inquiring about the mother’s tanning practices and asking her if she has started discussions with her child.59 Interventions directed at the mother may reduce her practices and lead to reduced tanning initiation and frequency of the child’s tanning.54 It should be noted that although parents may not approve of tanning indoors, they may have adopted a “pick your battles” strategy, feeling it to be more important to enforce rules on issues such as smoking or dating rather than focusing on tanning. For some teens and their families, this decision may have major health consequences. Table 5 lists some recommendations for integrating questions into practice.
Considering the teen’s perspective about tanning benefits may be helpful.60 She may be an “event tanner” preparing for a wedding or prom or may tan regularly as a mood enhancer or to relieve stress.61 Physicians may use open-ended questions, such as “How does having a tan make you feel?,” to gain insight and provide appropriate interventions. For “event tanners,” pediatricians may suggest substituting spray tanning or self-applied lotion to give a tanned appearance. An event tanner interested in appearance may also be receptive to information about indoor tanning as a cause of premature skin aging. For regular tanners who do so to relax and improve mood, physicians may suggest substituting running, dancing, or other aerobic activities.
Pediatricians have important roles in advocating for state laws to prevent minors from accessing tanning salons. Legislators who are parents and grandparents may be receptive to a pediatrician’s voice, particularly if the pediatrician is the family’s doctor. State-specific legislation should conform to FDA recommendations. Pediatricians also have a role at the federal level, working to change FDA classification of indoor tanning devices to class II or III and advocating for federal legislation to ban under-18 access.
Resources to help pediatricians address indoor tanning (akin to those that help clinicians discuss smoking cessation and secondhand smoke exposure) need to be developed. One model is the CEASE (Clinical Effort Against Secondhand Tobacco Exposure) Program developed to help clinicians counsel about smoking cessation and harm reduction by using written and video materials.62 Another is the American Academy of Pediatrics’ Julius B Richmond Center, which provides an array of education, training, and tools for clinicians.63 Resources are needed in academic settings, especially in pediatric settings, to train medical students and residents. Funding will be needed for all these efforts.
Research needs with regard to indoor tanning have been identified. Table 6 lists some of these areas.
Engaging families in discussions about tanning beds represents a unique and one of few cancer prevention opportunities for pediatricians. Evidence reveals that counseling is effective for youth and young persons aged 10 to 24 years. Discussions about UVR exposure, including artificial tanning, need to be integrated into health maintenance visits and should also occur at times when a teen arrives in the office with a tanned appearance or sunburn. A reasonable message is to “love the skin you’re in.” Pediatricians and dermatologists should work together, using their knowledge and perspectives to advocate for banning salon tanning for all minors. It is difficult to justify recreational exposure to a known carcinogen in any human population. Thus, child health advocates are working to encourage both state and federal governments to ban minors from indoor tanning. A long-term goal is banning indoor tanning for adults as well as teens, as has been done in Brazil and parts of Australia.
- Accepted October 17, 2012.
- Address correspondence to Sophie J. Balk, MD, 1621 Eastchester Rd, Bronx, NY 10461. E-mail:
Dr Balk conceptualized the article, drafted the initial manuscript, and approved the final manuscript as submitted; and Dr Fisher and Mr Geller conceptualized the article, critically reviewed and revised the article, and approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
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